Millions of Indians underwent traumatic experiences while seeking treatment during the COVID-19 pandemic. This strongly underlined the urgent need for two complementary streams of change in our healthcare system: strengthening public health services and regulating private healthcare providers. In the Indian context, no initiative for reforming the health sector will be complete without touching upon private healthcare, which accounts for around 70% of healthcare utilisation in the country.
The 2024 Forbes list of billionaires includes 200 Indians. Following manufacturing, the industry that contributes the second largest number of billionaires in India today (36), is healthcare, including pharmaceuticals. This number has increased every year, especially during and after the COVID-19 pandemic. Private healthcare in India is allowed to make high profits, because it is inadequately regulated and often charges patients exorbitant rates.
This setting underscores the relevance of policy recommendations contained in the recently published Jan Swasthya Abhiyan’s 18-point People’s Health Manifesto. It contains a wide range of inter-related policy recommendations covering diverse themes including public health services, the private healthcare sector, pharmaceutical policy, and the right to universal health care. Here, I briefly outline some key measures concerning the private healthcare sector in India.
Transparency, standardisation of rates
Private healthcare providers are perhaps unique among all the commercial services in India, since the rates of their services are generally not transparently available in the public domain. This is linked with the wide spectrum of rates that may be charged for the same procedure or treatment, not only by various hospitals in the same area, but also from different patients within the same hospital. The Clinical Establishments (Central Government) Rules, 2012 specify that all healthcare providers must display their rates and should charge standard rates as determined by the government from time to time. However, 12 years after these legal provisions were enacted, surprisingly they are yet to be implemented.
The Supreme Court has recently intervened in this matter, asking the Union Health Ministry to standardise healthcare rates as per the law. It is high time that transparency of healthcare rates be ensured, and standardisation of rates be implemented in an appropriate manner. This is technically feasible, keeping in view that thousands of private hospitals routinely accept reimbursement at standard rates for practically all common medical procedures, as part of large-scale official programmes such as the Central Government Health Scheme and Pradhan Mantri Jan Arogya Yojana. These measures can be legally ensured when the Clinical Establishment Rules are implemented or when State governments adopt improved Acts of their own, which include similar positive provisions.
It is also necessary to implement standard protocols to check irrational healthcare interventions, which are currently promoted on a wide scale due to commercial considerations. For example, the proportion of caesarean deliveries in India in private hospitals (48%) is three times higher compared to public hospitals (14%). In private hospitals, the share is far in excess of the medically recommended norm for caesarean sections (10-15% of all deliveries). Rationalising treatment practices and curbing excessive medical procedures will not just bring down excessive bills charged by many private hospitals, but also significantly improve healthcare outcomes for patients.
Implement patients’ rights
Given huge asymmetries of knowledge and power between patients and hospitals, certain rights are universally accepted to protect patients. These include the right of every patient to receive basic information about their condition and treatment, and the expected costs of care and itemised bills; the right to second opinion, informed consent, confidentiality and choice of provider for obtaining medicines or tests; and ensuring that no hospital should detain the body of a patient on any pretext.
In the Indian context, the National Human Rights Commission formulated a set of patients’ rights and responsibilities in 2018. Such a charter was circulated by the Union Health Ministry to all State governments in shorter form in 2019, and then in a more comprehensive form including 20 patients’ rights in 2021. However, given the lack of official attention given to these rights until now, the complete Patient Rights Charter (not a diluted version as observed in some hospitals) must be effectively enforced in all healthcare facilities across the country, so that patients and their caregivers can obtain care in a conducive environment. Creating such a secure setting would also help to rebuild much-needed trust between patients and providers.
Further, given the failure of existing mechanisms like Medical Councils to ensure justice for patients with serious complaints related to private hospitals, it is important that user-friendly grievance redressal systems be operationalised from district level upwards, with multi-stakeholder oversight.
Control commercialisation of colleges
Along with these measures on private healthcare, some complementary steps concerning medical education are mentioned in the manifesto. There is an urgent need to control commercialised private medical colleges, especially mandating that their fees must not be higher than government medical colleges. Further, expansion of medical education must be focused on public colleges rather than commercialised private institutions. The National Medical Commission needs independent, multi-stakeholder review and reform, keeping in view criticisms that this body lacks representation of diverse stakeholders, has excessively centralised decision-making, and tends towards further commercialisation of medical education. The National Eligibility-cum-Entrance Test (NEET) needs restructuring, since this tends to place candidates from less privileged backgrounds at a disadvantage, while encroaching on the autonomy of States in determining their own medical admission processes.
These vital measures for reforming private healthcare in public interest should be part of wider processes for developing a public-centred system of universal health care, based on major expansion and strengthening of public services, while engaging regulated private providers as per requirement. Drawing upon successful models such as the healthcare system in Thailand, such a system in India could provide rights-based access to free and quality healthcare to everyone.
Today, all political parties should commit themselves to implementing these transformations, while as citizens we must strongly demand them. This would be a fitting manner to celebrate World Health Day in India in 2024.
Dr Abhay Shukla is a public health specialist and a co-convenor of Jan Swasthya Abhiyan
